As reimbursement shifts, efficient patient throughput becomes critical

From the ED to discharge planning, case managers should be involved

With Medicare's stricter reimbursement guidelines and the likelihood that commercial payers will follow suit, it's more important than ever before for patients to move as quickly and safely as possible through the continuum of care, the experts say.

"Patient throughput has been of utmost importance since the DRG system was created. It's critical now that health care funds are getting so tight," says Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization at the North Shore-Long Island Jewish Health System in Great Neck, NY.

The Joint Commission initiated patient flow standards beginning in 2005 that call for hospitals to "develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital."

Over the past few years, hospitals have made great strides in improving length of stay and already have discovered and corrected the obvious glitches, Cesta says. "For the most part, the low-hanging fruit is gone, but most hospitals still have room to improve efficiency — so the question becomes where and how. Efficiency improvement is a much harder task than just improving length of stay," she says.

Patient flow affects patient safety, quality of care, efficiency, reimbursement, and patient satisfaction, Cesta points out.

For instance, the longer patients stay in the hospital, the more likely they are to develop a hospital-acquired infection. If a patient comes in with a broken hip and has to wait over the weekend before having surgery, it can affect the patient's recovery, putting him or her at increased potential for blood clots, falling, or infections.

Since the Centers for Medicare & Medicaid Services (CMS) has announced its intention not to pay for hospital-acquired conditions, keeping a patient longer than necessary can have a big impact on reimbursement.

A delay in one part of the hospital can affect what happens everywhere else, Cesta says. For instance, if you don't have vacant beds on the medical-surgical unit, patients may have to stay longer in the intensive care unit and surgical patients may have to stay in recovery a long time because no ICU beds are available for them.

To take it a step further, if there are no vacant beds in the recovery room, the patient has to stay in the operating room. Standards of care require the surgeon stay with the patient as long as he or she is in the operating room, Cesta points out. This affects the surgical start time for the next case, consequently making the operating room staff behind for the rest of the day.

Managing bottlenecks

"If you don't have patients in the right area at the right time, it has the domino effect of creating a bottleneck," adds Connie Commander, RN, CCM, ABDA, CPUR, president of Commander's Premier Consulting Corp. and immediate past president of the Case Management Society of America (CMSA).

Case managers should help assure that patients are moved as quickly and safely as possible to the appropriate levels of care, she says.

"Patients who sit in the emergency department for four hours or longer create inappropriate utilization of resources," Commander says. "What throughput is all about is evaluating patients, assessing their needs, determining what level of care they need, and moving them to that level, whether it's a higher or lower level of care." For instance, patients who are not in critical condition should not remain in the intensive care unit, even if their physician prefers the staff ratio in the ICU, she says.

"When noncritical patients are in an ICU bed, it can create a backlog but it's also a huge quality-of-care issue. The ICU staff know the patient is not meeting criteria for remaining in the intensive care unit. This takes away from the priorities of other critically ill patients who do require their attention," she says. The other impact is to the patient who should be moved to another level of care but who remains in the ICU, away from family and friends, perceiving that they are still at the critical level of care, she says.

Use skill set of clinical staff

The skill set of the clinical staff and the resources of the unit are not being utilized appropriately when patients aren't moved appropriately and in a timely manner through the continuum of care, she adds. When you talk with physicians about moving a patient to another level of care, it is helpful to tie it back into quality-of-care issues, including the fact that the bed could be used for another patient waiting for that ICU bed, Commander suggests.

"Physicians tend to be focused on the patient that is in front of them. We need to raise the awareness that while it may not hurt one patient to stay at a higher level of care than necessary, it is hurting the person who is holding somewhere else," she says.

Barriers to patient throughput can occur in all areas of the hospital but often begin in the emergency department, says Charlotte Thompson, RRT, BS, MBA, manager in KPMG LLP's health care advisory practice.

Good admission, discharge criteria

Case managers can play an integral role in patient flow, not just by discharging patients but by being involved in the intake process, she adds. "If hospitals don't utilize the right admission and discharge criteria, the patient may not be admitted to the right unit. Then they have to be moved and that becomes a patient safety issue and a patient satisfaction issue. It's been my experience that when there is a case manager in the emergency department, patients are admitted to the right unit the first time," she says.

When Thompson consults with hospitals about throughput initiatives, one of the first things she asks is: "Is there a case manager in the emergency department?"

Thompson recommends that hospitals assign a case manager to the emergency department and track the effect on patient flow over a period of time, including how many times patients are admitted to the right unit and how many patients meet admission criteria.

When there are delays in the emergency department, it's often because there are barriers to discharging inpatients in a timely manner, Thompson says. She advises hospitals look at where the barriers are occurring and what is clogging patient flow.

"In many instances, the problem is that inpatient beds are not freed up as quickly as they could be due to a lack of pre-planning," she says.

Discharge needs list

She suggests that case managers develop a patient discharge needs list, beginning when the patient is admitted.

"Instead of scrambling to set up everything the patient is going to need when the doctor writes the orders, the case managers should have discharge needs completed and in place in advance. Ordering equipment for the home, setting up a ride home, and a lot of other tasks can be completed in advance," she says.

Thompson was able to help the case management staff in one hospital decrease overall length of stay by half a day by pre-planning and making sure that everything was in place for patients to go home as soon as doctors wrote the discharge order.

Lack of communication often creates a barrier to discharge, Thompson points out. "Many times the patients and family members don't know when the patient will be discharged. I suggest placing a small white board in a patient's room near the door. The board should include the discharge date and the patient's responsibilities, such as setting up a ride home. This tiny white board can have a big impact," she says.

Communication key to flow

Good communication among members of the multidisciplinary treatment team can go a long way toward improving throughput, Thompson says. Set up visual cues about pending discharges where the entire treatment team can see them, whether it's on a chart or in the electronic patient/ bed tracking system.

"In today's busy health care environment, clinicians tend to operate in silos. When the team doesn't communicate effectively, it will affect the movement of the patient, whether it's intake, throughput, or discharge," she says. Thompson suggests group rounds that involve the entire treatment team, including case managers, and daily communication between the nurses, physicians, and case managers about the discharge process.

Discharging patients in a timely manner is important but it's merely the end of the throughput process, Cesta points out.

"Case managers must deal with utilization, patient flow, and coordination of care. Discharge planning is just another piece and it's not the only piece," Cesta says.

Don't fall into the trap of trying to discharge all patients by a certain time of day, she warns.

"Patients should leave the hospital when they are clinically ready to leave and everybody isn't clinically ready to go at 10 a.m., or 11 a.m., or noon. Some patients may be ready for discharge at 6 p.m.," she points out.

Discharging a lot of patients at the same time creates backlogs and taxes the resources of the hospital, Cesta says. Transportation, housekeeping, and other parts of the hospital will be overwhelmed if everyone is discharged at once, she adds.

Falling into that mindset has the potential to lengthen patient stays, she continues. For instance, if a patient isn't clinically ready to go home until late in the day and goes home at 6 p.m., does it count as a late discharge or is it an early discharge because the patient didn't stay overnight?

"If hospitals discharge patients throughout the day as they become clinically ready to go home, the beds can be ready to accommodate patients as they start to come into the emergency room," Cesta says.